Provider Demographics
NPI:1134189483
Name:SIVAKUMAR, BALASUBRAMANIAM (MD,)
Entity type:Individual
Prefix:
First Name:BALASUBRAMANIAM
Middle Name:
Last Name:SIVAKUMAR
Suffix:
Gender:M
Credentials:MD,
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5100 W TAFT RD
Mailing Address - Street 2:SUITE 2E
Mailing Address - City:LIVERPOOL
Mailing Address - State:NY
Mailing Address - Zip Code:13088-3807
Mailing Address - Country:US
Mailing Address - Phone:315-634-3399
Mailing Address - Fax:315-634-3395
Practice Address - Street 1:5100 W TAFT RD
Practice Address - Street 2:SUITE 2E
Practice Address - City:LIVERPOOL
Practice Address - State:NY
Practice Address - Zip Code:13088-3807
Practice Address - Country:US
Practice Address - Phone:315-634-3399
Practice Address - Fax:315-634-3395
Is Sole Proprietor?:No
Enumeration Date:2006-03-23
Last Update Date:2011-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY140339208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00812455Medicaid
NY53991HMedicare ID - Type Unspecified
NY00812455Medicaid